Diagnose and Cure Your ITB Problem

ITB pain is one of the most common running injuries I have seen in my twenty years working as a physiotherapist. Like a lot of running injuries, it is an “overuse” injury, meaning it is primarily caused by doing more running than your body can cope with.

Overuse injuries in runners are actually the end result of a combination of factors. Rarely are they due to one factor alone. This is why they can be so difficult to completely diagnose and “cure”.

Trying to find, and eliminate, the cause of an overuse running injury is like putting together pieces of a puzzle. You have to get all the little pieces in exactly the right place before you can fix the issue completely.

We have a 10-Week Return to Running Program which includes everything you need to make a fast and safe return to running from an ITB injury.

What factors can contribute to causing an ITB injury?
  • Overuse
  • Poor running technique
  • Tight / inflexible ankles
  • Poor pelvis stability
  • Weak/lazy glute muscles
  • Stiff hip joints
  • Overactive / tight hip flexor and quad muscles

In my experience the single biggest factor contributing to ITB injuries is from doing too much running too soon. Every time you run you cause damage to different parts of your body. Running damages your bone surfaces, your muscles and your tendons. When you rest, your body repairs these tissues, and when they repair they become slightly stronger. This is a process known as tissue adaptation. You have to get the correct ratio between damage and repair for the process to be “positive tissue adaptation” where, over time, your body adapts to the stress you are putting on it, becomes stronger, and can tolerate more running.

Overuse running injuries are caused by “negative tissue adaptation” where the amount of tissue damage created by your running volume is greater than your body’s ability to repair.

You can learn more about how to manage an overuse injury during your biggest training weeks by reading THIS ARTICLE


What is an ITB?

The ITB is a band of fascia which starts near your hip joint and runs down the outside of your thigh, attaching in and around the outside of the knee.
It originates from the gluteus maximus and Tensor Fascia Lata (TFL) muscles, and attaches into the patella (kneecap), tibia (shin bone) and fibula (smaller outside shin bone).


What does the ITB do?

The role of the ITB is to help keep your pelvis stable when you run and walk. It is the link between your pelvis and your lower leg. Interestingly, humans are the only primates with an ITB, and it is thought by evolutionary scientists to be one of the key factors in the survival of the human species as it allows us to run upright on two feet, and it is running on two feet which has allowed humans to be the most efficient endurance runners of all species.


Why does an ITB get painful?

ITB related pain most commonly occurs around the outside of your knee joint, and is usually felt anywhere from a few cm above your knee down to a few cms below it. The actual pain is thought to be caused by friction occurring where ITB rubs on the bone underneath.

The other, less common, site of ITB pain is around the outside of the hip joint where the ITB causes a rubbing, or friction, over a small sack of fluid called the trochanteric bursa. The bursa sits between the hip bone and the ITB.


How can you self-diagnose the cause of your ITB pain?

Because the cause of ITB pain is usually multifactorial, it is very difficult to diagnose. You need to work through the following tests one by one in order to identify and eliminate the cause of your pain. This step-by-step process could take anywhere from 2-3 weeks to a few months depending on how many of your tests are “positive”.

It is VITAL that you work through the whole list, in your own time, fixing each problem that you identify.


Test 1: Running Technique

One of the biggest contributing factors to ITB pain is poor running technique.

The three most important aspects of running technique that you should be aware of are:

  • Posture
  • Cadence
  • Stride Length

Posture: You should stand up tall when you run and avoid bending forward from the hips. Standing tall helps to shorten your stride length, and also improves your ability to breathe as it opens up the chest and allows your diaphragm to work more efficiently.
Cadence: Cadence refers to the number of steps per minute you take. There is a range of cadence which is thought to be most efficient for humans. This range is between 175-185 steps/minute. Read THIS ARTICLE about cadence, to learn more, and to find out exactly how to measure and improve yours.
Stride Length: By stride length, I am referring to where your foot first contacts the ground in relation to where your bodyweight, or centre of mass, sits. One of the most common running technique faults I see is “overstriding” which means running with your foot landing out in front of your body.


Test 2: Single Leg Stability

Does your pelvis stay level when you bob up and down on one foot? If your pelvis drops and/or rotates when you bob up and down on one foot, then here is a good chance the same thing happens when you run. It just happens too quickly for it to be obvious.

  • Watch THIS VIDEO which defines “core stability” or “pelvis stability” in a runner.
  • Try the easy test in the VIDEO in this article to test your own pelvis stability and learn how to improve it.


Test 3: Stiff ankles and/or calf muscles

Stiff ankles and/or very tight calf muscles can restrict how far forward your knee is able to travel over your toes when you run. If the range of movement through your ankle is limited, then once you reach that limit, it can make your knee drop inwards which in turn causes your pelvis to drop.

Having one ankle stiffer than the other is probably the single biggest biomechanical trait I see in runners which causes ITB pain. One ankle might be stiffer due to an old ankle sprain or a calf muscle injury for example. It doesn’t have to be a recent one either. I often see runners with an ankle that was sprained 20 years ago who are completely unaware that it is stiff, let alone causing their ITB issue.

To improve your ankle mobility and calf flexibility I recommend you follow my 3-Minute Morning Stretching Routine

Watch this detailed video on ankle mobility so you know how to test your own mobility and learn how to fix it.

Test 4: Tight Quads

Tight quad muscles, especially the lateral quads which run down the outside/front of your thigh, can contribute to ITB problems and lateral knee pain.

Learn how to STRETCH YOUR QUADS properly, and also how to USE A FOAM ROLLER to release the tension.


Test 5: Lazy Glutes

Our modern lifestyle where the bulk of our day is spent sitting, is a huge contributing factor to the muscular imbalances that occur in our body. These imbalances tend to lead towards the combination of lazy glute muscles and overactive and tight hip flexors and quads.

Think about your average day. How many hours do you spend sitting? Try and work it out. How many hours do you spend sitting:

  • During breakfast
  • Commuting to work
  • At work
  • At lunch
  • Commuting home from work
  • At dinner
  • On the sofa watching TV or reading?

How many hours do you spend running, walking or moving every day?

It is often a scary ratio.

Our bodies are incredibly efficient at adapting to our environment. If you spend 10 hours per day sitting, and two hours per day moving, then your body is gradually going to become better at sitting than standing. This process starts from a surprisingly young age. The flexibility in the average 9-10 year old child I have treated is significantly less than the flexibility of the average pre school child. By the age of 9 or 10, sitting has already had an effect on the hamstrings, hips and ankle flexibility. Imagine what has happened by the age of 40 or 50!

You can do an easy test to find out if your glutes are “lazy”. Being able to “switch on” your glutes is essential if you are going to try to correct any imbalance which exists between your glutes and your quads.

Watch THIS VIDEO to learn everything you need to know about activating and strengthening your glutes

Before you start on any sort of glute strengthening program you need to master this glute activation exercise and learn to tell the difference between using your glutes and using your quads. A lot of health care professionals and personal trainers prescribe glute strengthening exercises like squats and lunges to people who are not actually able to consciously activate their glutes. This often exacerbates ITB pain because the squats and lunges, in this case, add to the glute/quad imbalance rather than help it.


Test 6: Stiff hips

Another common side effect of our modern lifestyle is stiff hip joints. Too much time spent sitting, and not enough time spent getting into positions which open up and stretch the muscles, ligaments and fascia around the hip joint (like the HG Squat for example) has led to stiff hip joints. Stiff hips can lead to further muscle imbalances which affect the ITB.

We have a number of stretches and exercises on The Locker Room dedicated to improving your hip mobility. You can learn all of them during a FREE 7 Day Trial

Our 3-Minute Morning Stretching Routine will also help to improve your hip mobility.


How quickly can you return to running following an ITB injury?

The answer to this question will differ from person to person depending on the severity and duration of your symptoms. Read THIS ARTICLE to find out how to reintroduce running in a safe a graduated fashion, to ensure you don’t accidentally return to quickly an undo all of the hard work you have achieved by identifying and eliminating the cause of your ITB pain.

We also have a 10-Week Return to Running Program which includes everything you need to make a fast and safe return to running from an ITB injury.

What can you do to prevent the symptoms coming back?

In order to prevent your ITB pain recurring you need to run through these 6 tests again once every month. Once you become familiar with them, the whole process will take less than 10 minutes. If you tests “positive” again for any of them, you need to work through the prescribed exercises again.

The best way however to prevent recurrence is to start an easy daily body maintenance routine which works on your flexibility and your stability.

Our 3-Minute Morning Stretching Routine and our 10-Minute Core Strengthening Videos are perfect for your daily body maintenance training.